PECOS Delay – Official Announcement

CMS has added  an MLN Matters article about the PECOS delay which was announced earlier this week.  It is titled:  SE1305 – Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856).

NAHC  has posed the following questions to CMS:

  1. Must home health agencies issue a beneficiary notice to patients whose services will be terminated because of failure of their physician to be enrolled in PECOS and, if so, what notice?
  2. May home health agencies hold beneficiaries liable for the cost of care?
  3. Do apostrophes appear in PECOS files and in the edit files that will be used by the MACs (conflicting guidance from CMS to providers about use of apostrophes)
  4. Will claims be edited against the original Phase 2 May 1, 2013 “from” date or will this date be amended?
  5. Would CMS please add the effective date of physician enrollment to the Ordering/Referring File?

The Alliance appreciates NAHC pushing for these answers and will share information as we get it.

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National Provider Call: Activation of PECOS Edit May 1

Register for the National Provider Call on Wednesday, March 20; 3-4pm

CMS will hold a national provider call on March 20 from 3-4pm ET on the “Implementation of Phase 2 Edits on the Ordering/Referring Providers in Medicare Part B and Part A -Home Health Agency Claims.”

Effective May 1, 2013, CMS will instruct contractors to turn on Phase 2 denial edits; checking Medicare claims for home health services ordered by physicians who are not enrolled in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). If physicians are not enrolled these claims will be denied.

In order to receive call-in information, you must register  on the CMS website CMS Upcoming National Provider Calls. During the registration process, advanced questions may be posted

National Provider Call Agenda:

  • Provider Types Eligible to Order/Refer
  • Action Steps for Billing Providers
  • Action Steps for  Providers Who Order/Refer
  • Resources

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Are You Prepared for the May1st PECOS Edit?

Effective May 1st, CMS will deny home health claims where the physician on the claim does not have an enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS).

CMS released MLN Matters-SE1305, on March 1st, detailing information regarding this new “phase 2” edit.  Phase 2 is part of CMS’s implementation of Section 6450 of the Affordable Care Act, which requires physicians or other eligible professionals to be enrolled in the Medicare Program to order or refer items or services for Medicare beneficiaries, even if those physicians do not directly bill Medicare for any services.

Home Health claims will be denied with one of two reason codes, according to the March 1st MLN Matters article:

  • 37236: The statement “from” date is on or after May 1, the type of bill is “32” or “33” and the attending physician’s national provider identifier (NPI) is not present in PECOS. The claim could also be denied if the NPI is present in PECOS but the name given on the claim doesn’t match the one on the physician’s enrollment record.
  • 37237: Same as above, but this denial reason code will be assigned only when the type of bill frequency code is “7,” which indicates an adjustment, or “F-P.”

Check your referring physicians’ status in PECOS; agencies may be forced to hold billing the claim for physicians who are not enrolled.

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CMS Releases Updated Information about PECOS

Are your ordering/referring  physicians enrolled in PECOS?

On June 20th CMS released a revised MLN Matters article with updated information regarding PECOS and Phase 2 of the Ordering/Referring Physician Requirements.

During Phase 2, Medicare will deny Part A HHA claims that fail the ordering/referring provider edits. CMS has not announced a date when the edits for Phase 2 will become active. CMS will give the provider community at least 60 days notice prior to turning on these edits. Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record (PECOS).

It is possible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to process enrollment applications. All enrollment applications, including those submitted over the web, require verification of the information reported. Sometimes, Medicare enrollment contractors may request additional information in order to process the enrollment application.

Waiting too late to begin this process could mean that physicians’ enrollment applications will not be able to be processed prior to the implementation date of Phase 2 of the ordering/referring provider edits. In Phase 2, if the Ordering/Referring Provider does not pass the edits, the claim will be denied.This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral. For more information Click Here

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Avoid Denied Claims-Follow Medicare’s Provider Enrollment Guidelines.

As reported in the HCA’s Update last week, CMS published in the Federal Register  “Medicare and Medicaid Programs: Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreement.”

This final rule finalizes several provisions of the Affordable Care Act implemented in the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. In addition, it requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare.

To receive payment for home health services, any Medicare-enrolled Home Health Agency must file claims containing the name and National Provider Identifier (NPI) of the physician who ordered the service.

The ordering physician must be enrolled in PECOS. The NPI used must be for an individual physician (cannot be a group or organizational NPI) and the individual physician must be of a specialist type that is eligible to order; Doctors of Medicine or Osteopathy, Doctors of Podiatric Medicine

Failure to meet the requirements mentioned above will result in denied claims once the automatic edits are activated.  The Medicare Learning Network’s “Medicare Enrollment Guidelines for Ordering/Referring Providers” is an excellent fact sheet if you need more information

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HHAs Must Ensure Physician Enrollment in Medicare

 CMS Releases:  Ordering and Referring Physician Final Rule

On Tuesday, CMS posted for public inspection the final rule “Medicare and Medicaid Programs: Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreement” This document was published in the Federal Register on 04/27/2012.

This rule requires enrollment of physicians ordering home health and other services to be enrolled in the Provider Enrollment, Chain, and Ownership System (PECOS). Work is underway to transition all physicians enrolled in other systems, such as the Legacy system, to PECOS. This process is being expedited by CMS through physician Medicare re-validation.

Home health agencies should  begin checking every physicians Medicare enrollment status in the Ordering and Referring Physician report. Through this report CMS has made available the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI).
A new file will be made available periodically that will replace the posted file; at any given time, only the most recent file will be available. It can also be used to search for a particular physician or non physician practitioner by NPI number or by name.
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